Catheter, Pressure Injury, and Discharge Planning After Hip Fracture
An 88-year-old man is in a skilled nursing facility 3 weeks after a hip hemiarthroplasty for a fall. He has urinary incontinence, an indwelling catheter placed in the hospital, a stage 2 pressure injury over the sacrum, and deconditioning. He wants to go home alone; his family is unsure. Medications: warfarin for atrial fibrillation, metoprolol, furosemide, and oxybutynin. He has 4/5 strength on the left and uses a walker with assistance. He lives in a one-bedroom apartment with four steps to the entrance. He has no fever; urinalysis shows pyuria but no nitrite.
1. Should the indwelling catheter be removed now? Outline a trial without catheter and contingencies.
Read the worked answer
Yes, unless there is a specific ongoing indication such as urinary retention or a sacral wound requiring strict moisture control-and even then the benefit is limited. Prolonged catheterization increases CAUTI, stones, and delirium risk. I would remove it and start a timed toileting program with prompted voiding, adequate fluids, and bedside commode access. Monitor voiding and use a bladder scan for retention; if he cannot void or postvoid residual is persistently high, start intermittent catheterization rather than immediately replacing an indwelling catheter. Stop oxybutynin if it is contributing to retention. If a catheter is unavoidable, use a securement device and closed drainage. Document the trial and contingency plan.
2. How would you stage and manage the sacral pressure injury, and what reassessment schedule?
Read the worked answer
A stage 2 injury is partial-thickness loss of dermis, presenting as a shallow open ulcer or intact/ruptured blister without slough. Manage with a moisture-retentive dressing, offloading, repositioning at least every 2 hours, and avoidance of friction and shear. Keep the area clean and protect the surrounding skin; do not massage. Optimize nutrition and treat incontinence moisture. Measure and photograph the wound weekly; if it does not improve in 2–4 weeks or deepens, reassess for stage change, infection, or osteomyelitis. Escalate to wound care if there is slough, eschar, purulence, or surrounding erythema.
3. What discharge planning is needed to support home safety and continence care?
Read the worked answer
He wants to go home alone, so I would require an OT home evaluation for the four steps, bathroom, and bedroom; PT for gait and transfer training; and a home health aide or family plan for toileting, meals, and medications. Equipment includes a walker, shower chair, commode, and incontinence supplies. I would review medications, especially warfarin monitoring and furosemide timing, and arrange follow-up. I would assess whether he can manage catheter care or intermittent catheterization and whether he can call for help. If safety cannot be assured, I would discuss a short supervised stay or assisted living rather than simply agreeing to discharge.